For the physical exam you definitely wanna make sure
you’re focusing on your neurologic exam.
You wanna test the cranial nerves.
You wanna have the patient talk to you.
Are they able to talk clearly?
Do they feel like their voice is slurred or that their speech is slurred?
Sometimes that may be a little bit subtle so it can helpful to ask the patient
do you think your voice sounds like it normally does?
You wanna look at the pupillary size.
You wanna see of the pupils are asymmetric,
if they’re both reactive or not reacting appropriately.
You wanna make sure they can move their eyes all around
so you have them look up,
down, to the right, to the left and test their extraocular movements
and you wanna make sure you go through all the rest
of your cranial nerve testing.
You wanna do a motor and sensory exam.
You wanna test the strength in their upper extremities
and their lower extremities
and you wanna test for pronator drift by having them hold up their arms.
I always tell patients, hold up your arms
like you’re holding two bowls of soup in your hands
and seeing if there are hand drifts in or doesn’t drift in.
And then you wanna do cerebellar testing.
Cerebellar testing—I always tell people,
you know, we’re gonna do some silly moves here,
because the things that you have them do
are a little bit funny to them sometimes
so you have them touch their finger to their nose
and then touch your finger and then heel to shin.
You have them run their heel along their shin.
You wanna check their reflexes and you wanna check a Babinski reflex.
To check a Babinski you take a sharp object
and you run it along the bottom of their foot
and you see if their toe goes down or up their great toe
and then you wanna test their gait.
A key thing about gait testing is that
it’s such an important part of the neurologic exam
and it’s something that can be hard to figure out
unless you actually have the patient stand up and walk.
But you wanna make sure you’re doing it in a safe environment
especially if you’re a smaller person
and you’re trying to walk someone that’s a big, tall person
definitely, you wanna make sure that you have an extra set of hands
just in case that person is very unsteady on their feet
and if they were to fall down
you wanna make sure that they’re in a safe environment.
Generally, when I get people up to walk them
I took an idea to have them walk regularly
and then to have them do a heel-toe walk.
So basically, I tell people to walk like you’re walking along a tight rope.
Things that you may see if it’s concerning or like a wide-based gait
or a patient that’s not able to really walk effectively.
When talking about ischemic stroke
we also talk about different scoring systems.
The reason that we talk about these scoring systems
is because we’re trying to help determine:
A. where our patients should be brought to the hospital
and also to try and figure out what is the next step for the patient?
What is the next appropriate treatment?
So there’s 2 prehospital scores
and the use of these may vary base on where you’re located
and what kind of facility you’re at
but there’s a Cincinnati prehospital stroke scale
and then the Los Angeles prehospital stroke scale.
And the reason that these have been established and developed
is because their goal is to help EMS, the paramedics,
determine the best hospital to bring the patient to.
So if the patient has a higher stroke scale
and potentially may need the indication for TPA or a clot busting medication,
they bring those patients to a designated stroke center.
So to a place that is common and used to caring for patients
who are having strokes
or if their stroke scale is lower
or if there’s less of a suspicion for a stroke,
that patient can potentially go to a hospital
that doesn’t have those capabilities.
The last stroke scale is the NIH stroke scale
and this is the one that’s used most commonly
when a patient arrives in the hospital
either performed by the Emergency Medicine physician
or the neurologic team that’s coming down
to evaluate the patient or potentially in conjunction.
The goal of the stroke scale is to figure out and calculate a number
and then from that number based on what it is to determine
if that patient needs criteria for TPA,
the clot busting medication.
So just too quickly look at the Cincinnati pre hospital stroke scale,
it tests three different things.
So the first is facial droop.
A normal would be that both sides of the face move equally.
An abnormal would be that one side of the face does not move at all
so that’s indicating that there’s a facial droop on one side.
The next is arm drift.
That’s the pronator drift that we talked about
where both arms are placed out like they’re holding bowls of soup.
In a normal patient, both arms move equally or not at all.
And in the other one, one arm drifts inside inwardly compared to the other.
Speech is the last component here.
So normal is that the patient uses the correct words
with no slurring of the speech.
An abnormal would be that the patient has slurred words
or inappropriate words or isn’t able to speak.
So you get a point for each of these.